Predictors of Leisure Participation in 6 to 14-Year-Old Children with Cerebral Palsy: Structural Equation Modeling.

Objective: The aim of this study was to test a model of child, family and environment and identify factors affecting the intensity of leisure participation by children with cerebral palsy (CP). Materials & Methods: In this cross-sectional study, 232 children with cerebral palsy (141 boys and 91 girls), aged 6 to 14 years old and their parents were selected from four schools of children with special needs and five rehabilitation centers through the convenience sampling method in Shiraz, Iran. To evaluate the intensity of leisure participation, we used the Persian version of Children’s Assessment of Participation and Enjoyment (CAPE) completed by the participants. Demographic form, Craig Hospital Inventory of Environmental Factors (CHIEF), Strengths and Difficulties Questionnaire (SDQ), Family Environmental Scale (FES), SPARCLE cognitive level and parents' version of Gross Motor Function Classification System, Manual Ability Classification System and Communication Function Classification System were sent to the parents with some necessary explanations. Structural equation modeling was used to test the model hypothesis. SPSS version 18 and AMOS version 16 were used for data analysis. Results: Comparative fit indexes indicated a moderate to good model fit. The presented model explained 44% of the variance in the intensity of participation. Constructs such as Family Activity Orientation with standardized total effect of 0.31 and path coefficients of P< .05 showed the most significant direct effect on participation, followed by higher gross motor function (-.26), higher manual ability (-.19), communication function (-.17), higher cognitive level (-.16), more siblings in the family (.15) and less emotional-behavioral problems (-.15). Family structures and relationships (.17) and unsupportive environment constructs (-.14) demonstrated an indirect but significant effect (P< .05). The relationship of family education level and income with participation was not significant (P>.05). Conclusion: The intensity of CP children’s participation is influenced by child, family and environmental factors. Parents' knowledge of recreational activities and their preference to participate in leisure and recreational activities provide children more opportunities to participate. Higher gross motor function, manual ability, and communication function also play an important role in their participation. Family structure means family cohesion, roles organization, and conflicts between family members and encountering physical, attitudinal and structural barriers at home and community indirectly impact children’s participation pattern. To enhance children’s participation, we suggest therapists to support children’s behaviors, family relationships and involvement in community activities and optimize physical function of children with limitations in self-mobility.


Introduction
Participation has both subjective and objective aspects and it means engagement in life situations (1). Children's participation is an important and complex issue that changes with social and cultural contexts of each society (2). Leisure includes voluntary activities that children engage in within their free time with internal motivation (3). It is also an important occupational concept and children spend 30% of their time participating in these activities (4). Leisure activities include athletic, skill-based, physical, recreational and self-improvement activities. Participation in these activities improve children's physical, social and emotional development, relationships and performance in their home, school and community roles (5). However, most children with physical disabilities perform recreational activities in solitude in home-restricted contexts (6).

Most Iranian articles addressed child participation
in activities of daily living, while participation in none of the eight occupation areas is superior to the other (3,7). Although weakness of cerebral palsy students in leisure activities compared to Iran J Child Neurol. Spring 2020 Vol. 14 No. 2 their normal peers has been reported, there are few studies focusing on their leisure and recreational activities (8,9). King

Child-related factors:
We proposed that: The constructs gross motor function, children manual ability, cognitive level, communication function level, emotional and behavioral problems, and age have a direct effect on participation (4,12,15). In fact, children with better physical functioning experience fewer limitations and barriers to participation than those with weak motor ability (16,17). Cerebral palsy children who do not have behavioral problems and have better communication functions are more likely to be involved in leisure activities along with family and friends (10). We also proposed that high intelligence is related to high rate of leisure participation (15,18).

Family-related factors
We proposed: Family activity orientation (family's interest for social, logical and cultural activities and their participation in recreational activities) is related to high rate of children's participation (10,12). Primary caregiver education and financial resources are associated with family's intellectualcultural orientation and its preferences for recreation and higher child participation (12,19,20). Family structures and relationships (i.e., family cohesion, conflicts, activities and roles organization) could change family activity orientation and indirectly promote child participation (10,12), also it can influence emotional and behavioral problems and indirectly change child's participation pattern (21).
We predicted that the number of siblings and being among peers and friends can increase confidence, motivation and psychosocial support for disabled children and is related to high child participation (22).

Environment-related factors
We proposed that unsupportive physical, attitudinal and social environments, for example, personal assistant services, others' prejudices, lack of information and architectural barriers are related to family structures and relationships and child's emotional behaviors (because disability in participation is seen as a person's problem in relation to the environment and facilitating or unsupportive environment affects child's emotional and behavioral functions), and therefore, higher child participation (10,21,23).

Unsupportive environment and income interacted
with each other because lower/higher income cause facing less/more environmental barriers (lack of assistant, access to transportation system and accommodation) (24).
Our research objective, which was to test the model of factors influencing the rate of Iranian cerebral palsy children's participation in leisure activities.
Identifying the predictors can help therapists, families, managers, and policymakers to know "which levels of child, family or environment are better to plan on and which factors should be more focused on?"

Participants
In this cross-sectional study, we enrolled 232 cerebral palsy children aged 6 to 14 years old (mean age: 9y 3mo, SD 2.5y) and their parents.

Measurement Model
For data analysis and investigating the relationship between factors and determine the role of each variable, first we tested the reliability of the measurement model. Factor analysis was used to examined the reliability and indicators loading of each construct. The loadings of the measured indicators on the factors were of acceptable magnitude (Table2) (31). Then, we determined the correlation among variables (Table 3). function had a direct effect on child participation (10,12). Other studies on leisure participation and daily life activities also indicated the importance of gross motor, manual ability, the communication function and intelligence in child participation (15)(16)(17)(18)32). In two studies, the association of gross motor function and mobility with participation was not significant because of multiple sites sampling and various physical impairments (13,33).
The main result of this study was the importance of family-related factors, the role of family intellectual-cultural orientation and family preferences to engage in recreation activities.
In Family Activity Orientation construct with and environmental factors with 40% and 24% of variance were more significant than family factors (18), this difference might be due to the difference in Iranian society.
Another noticeable factor was siblings of the children, having brothers and sisters increase motivation, self-confidence and support in disabled children, and therefore, promote their participation. Interpersonal, social and supportive relationships with close friends, teachers and peers are associated with high child participation (10,13,21). This study also emphasized that normal behaviors could increase total participation by 15%. Emotional-behavioral problems, for example isolation, hyperactivity and aggression impede the child to participate normally in plays and recreations, because based on behavioral treatment approach, behavioral problems decrease adaptability, coping ability and sense of mastery in activities (10,15

In Conclusion
Our in several studies, the role of family stress and child preferences to participate were mentioned, which was not possible to complete due to the time limit.
We did not measure the intelligence score because we did not have the time and financial resources to administer a standardized measure of intelligence.

Acknowledgement
We wish to thank Dr.  All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflicts of interest
The authors declare no conflicts of interest.